DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Friday, 28 January 2011

It's been a while since I last wrote on this blog. I'm afraid I've been very busy but I nevertheless have not forgotten about the blog.

From my experiences in Japan, patients are often discussed around computer terminals with much emphasis given to laboratory data and radiology rather than the history and examination. This is nothing new to this blog but the fact that the patients are seen for just a short time and given a cursory examination, is not what I would classify as a clinical round.

In other countries such as USA, Australia and the UK, although there is also discussion about data and scans, their emphasis is not put before the history and physical examination of the patient.

Clinical interpretations, decision making, treatments etc are based upon the combined picture of all elements including what was or was not found in the history and on the physical examination with the addition of basic tests e.g. blood tests, ECG, chest x-ray. Decisions are not based only on tests. In the emergency situation, withholding treatment while awaiting test results can end up with a dead patient. For example, a tension pneumothorax is a clinical diagnosis and sending the patient for a chest X-ray would be viewed as malpractice and even incompetence. A needle thorocotomy at the bedside is a diagnostic therapy and fully justified in such a situation.

When reviewing patients on the ward rounds, clinical signs need to be re-elicited to determine if there is a worsening or an improvement. It is not often necessary to keep repeating laboratory data daily (unless the patient is very unwell) or 'following the X-ray' or perhaps more commonly, 'following the CT'. One must remember that patient signs e.g. crackles of pneumonia, can disappear before the radiograph resolution. Hence, following a scan may prove to be less accurate than the physical examination. One must actually 'follow the patient' and not waste time with unnecessary, costly, tests when simply percussing, palpating and listening can tell you if there is an improvement or not and without cost.

On ward rounds, unwell patients need daily physical examination or even more frequently if the clinical need arises. A simple few words and a wave is not sufficient. It does not tell you what is going on with the patient. Moreover, laying on of hands is invaluable as it tells the doctor sometimes more information than a blood test or an xray. In addition, patient satisfaction is better because it shows that the medical staff are actually interested in finding the problem.

There have been situations when a full physical examination of the patient has resulted in the patient developing a 'welling look' and comments including 'I have never been examined in such detail before. Thank you.', 'I've been in hospital for many weeks and this is the first time I have been examined properly'. Family members are also highly satisfied if the medical staff show real interest and examine.

In addition, although it is not commonplace for medical staff to ask many questions as it is viewed as a kind of 'rudeness' to inquire and can be embarrassing, that kind of way will result in diagnoses being missed as the question(s) was/were never posed. Better to ask more questions by asking 'why' than be scolded by a senior doctor later with them asking you 'why not !'

Hence, ward rounds done on paper / electronically of course have their place, but they should not be the only component of a ward round. Patients need to asked more questions to help narrow down the current problems and physical examination should be performed for reassessment.

All conversation information and physical examination needs to be properly noted (under subjective and objective in the SOAP format of notation) at the time it takes place and not hours later. Remember that such information is the basis of a legal document and if not written down immediately, essential information can be and is often missed. This can lead to inaccuracies and wrong tests / treatments being ordered or not ordered at all.

Treatments need to always be re-evaluated. Antibiotics, dose, frequency, side effects, and the patient response to such therapy needs to always be considered. Moreover, rather than just starting antibiotics and forgetting about the stop-date, such treatment always needs to be revisited to decide on when to complete the course. If the patient does not respond appropriately, there can be several reasons which need to be considered:

1) The antibiotic is not covering the organism(s) e.g. anaerobic bacteria2) The dose / frequency is too low3) The patient has immune suppression4) The bacteria has resistance to the antibiotic5) A non-bacterial cause is present e.g. pulmonary embolism, vasculitis, fungal infection6) A collection has formed e.g. lung abscess, valve ring abscess, sub-phrenic abscess7) There may be a drug-fever; patients need to always be asked if they have ever had a reaction to drugs with antibiotics being a particularly common problem8) There is a line infection e.g. prolonged use of central lines causing candida bacteremia

Hence, simply switching to a 'napalm-kill everything' carbapenem that kills indiscriminately is not always the answer. The bacteria may be very sensitive to the original antibiotic e.g. penicillin, but it may be one or more of the above elements that is resulting in failure of resolution. Switching to a 'penem' will of course be useless if there is candidemia, abscess formation, PE.

Carbapenem usage should not be first line except in certain situations e.g. neutropenic sepsis. Because antibiotics are strictly managed by microbiologists, pharmacists and infectious disease doctors in places such as the UK, Australia and the USA, carbapenem use is far less. In many situations, it is 3rd or 4th line but almost never first line.

Hence, evaluating where infection may be coming from rather than pumping in a 'penem' and hoping for the best is essential to ensure that the patient is receiving appropriate care.

As I have mentioned, commencing antibiotics needs deep consideration but stopping them is also a very important thing.

The usual way of stopping antibiotics is when the clinical features and (e.g. symptoms and signs), vital signs improve e.g. fever resolution, the patient feeling better, and with the hematologic parameters returning towards normal, which is sometimes not practiced in some institutions. Patients are sometimes maintained on intravenous antibiotics for weeks on end even though the patient is well, mobilising, eating and drinking for the mere fact that the C-reactive protein (CRP) is still elevated. I have heard of a case in a university hospital, whereby a patient who was well post-surgery had an elevation of the CRP and which was the sole clinical indication to re-operation. This way is not advocated. The CRP is indeed a better indicator that the laboratory is open.

When making clinical decisions, all elements must be taken into account and not a non-specific lab test.

Of course, infection causes inflammation, and even after the bacteria have been eliminated, the inflammation may persist for several days or even several weeks thereby elevating the CRP. But if the patient is feeling better, fever, signs of sepsis have resolved and other parameters are returning to normal, there is no indication to continue intravenous antibiotics. They can be switched to short-course oral treatment or even discontinued depending on the clinical situation. Exceptions are for chronic or difficult to treat infections such as osteomyelitis and endocarditis that require many weeks of antibiotics. However, for an uncomplicated pneumonia or a urinary tract infection which are exceedingly common, short course antibiotics with clinical reevaluation and early de-escalation is best to avoid prolonged hospital stay, reduce antibiotics pressure on bacteria and to reduce cost to the patient.

Remember that if a patient is on drugs that could be causing worsening of their condition e.g. ACE inhibitors, anti-psychotic drugs etc, they should be stopped to evaluate if they are the cause and to observe for resolution. An excellent resident recently keenly noted that in a patient with an FUO for 6 months, that all investigations offered up no cause. Only on instituting a 'drug holiday' of stopping all drugs, did the fever abate, inflammatory markers rapidly dropped and patient could eat and mobilize!

I can't emphasize enough the importance of bedside history taking, re-evaluation by physical examination, and re-evalautuon of drug treatments etc. Clinical examination can avoid the 'follow the CT' reflex and avoid radiation. Your patients will be much more satisfied that you've taken the time to lay hands on them to evaluate them than sending them into the 'tube of truth' to come out empty handed.

However, as a word of warning, if you do find an abnormal clinical examination e.g. unequal pulses and BPs in a patient with central tearing chest pain, the physical exam directs the physician to obtain appropriate scans and institute life saving treatment.

Without the tools of history and physical examination, we as doctors are shooting in the dark and using a sledgehammer to crack a walnut with routine CT scanning for simple pneumonias that can be diagnosed simply by traditional methods and a simple X-ray. Without the basic tools and over-reliance on the 'machine', we end up slaves to the machine and practicing defensive medicine when no such defense is necessary or warranted.

In the end, it comes down to clinical reasoning which can only be learned from experienced staff adept in managing the many conditions that medicine throws at us on a daily basis. The PC is not a patient and cannot speak or elicit signs. Better to go to the bedside. The patient will tell you more than any book or webpage.